Wednesday, July 25, 2007

Those Amazing Thickened Liquids

So last week I had one of those situations that just makes you want to bang your head against the wall. Over and over. Or maybe throw things, but that can get you in trouble. But I digress...

Patient had an old stroke, but no significant residual dysphagia. After my initial eval, the patient was placed on a regular diet with thin liquids. I followed up for a meal monitor, just to make sure everything was okay... no problems.

A few days later, I was asked to see the patient again. Worsening medical status? New difficulty with meals? Pneumonia? Nope, the doctor heard "wheezing" during morning rounds and thought the patient "might have aspirated saliva," and so placed the patient on thickened liquids and asked for a reassessment. The reassessment is no problem, but how on earth does one expect thickened liquids to prevent the aspiration OF SALIVA? Never mind the completely erroneous assumption that thickened liquids are somehow inherently "safer".

So the patient is exactly the same as before, which is to say, not a significant prandial (mealtime) aspiration risk, so I recommend resuming the regular diet.

The next day I check the chart and discover that (1) the doctor is ticked that I didn't do a VFSS (hello, if you want that done, you have to WRITE AN ORDER FOR IT, or at least mention it in the progress notes so I know that's the "reassessment" you want!), and (2) the doctor knows I recommended the regular diet, but writes to continue thickened liquids to "make sure the patient doesn't aspirate gastric secretions."

So, not only do those amazing thickened liquids prevent the aspiration of saliva, they also prevent aspiration of reflux! Just wait til the surgeons find out! Never mind pre-op NPO status, just put patients on thickened liquids! (I'm sure the thickener companies wouldn't object...)

Gah. Anyways, I did correct the misinformation (there is NO EVIDENCE that thickened liquids prevent aspiration of gastric secretions, or aspiration of anything, really) and the patient was placed back on a regular diet at last (after a completely normal VFSS, no less). So all's well that ends well, but that reasoning was certainly a new one for me!

8 Comments:

Ha ha! Don't you just love the decisions and reasoning behind some doctors? Geez they can be a baffling bunch sometimes!

I was cringing on the ward the other day when I heard a prominent neurologist talking a bunch of medical students about the importance of a gag reflex assessment as a predictor of swallowing function! Arrggghh! Now it's my turn to bang my head against a wall! I wanted to quietly slip the students one of the many research papers proving otherwise!

You have to catch 'em while they're young. Usually you can get residents to at least listen to you, especially if you mention "evidence-based practice" and toss in some journal articles. Once they're out of residency, it's usually a much different story!

I haven't run across the old "gag reflex" myth for a while (I'm probably jinxing myself now) -- but boy does it drive me crazy when I do!

Just found your blog! I am also an SLP that works in acute care, at the regional trauma hospital. I look forward to following your blog. :D Our hospital is a training hospital for residents and medical students, who are all IDIOTS. They really don't know anything, and we have to teach them, *sigh*.

My favorite rationale: The assessment is therapeutic. If you don't get the results you want (e.g. recommendation is NPO), just reorder the test - sometimes as soon as 45 minutes later. Geez.

Hi there! I am a travel SLP currently doing home health care. I discovered your site as I was searching for a decent caregiver handout on signs/symptoms of silent aspiration (and stumbled upon nursing-oriented educational materials interchanging dysphagia and aspiration because we all know they mean the same thing). I hear ya on the rampant misinformation out there. Magical thickened liquids goes right up there with giving forks and knives to advanced dementia patients on puree. I'll be back on your site for sure!

About Me

I am a speech-language pathologist (SLP) working in acute care. I enjoy writing about my experiences and speech-related topics to reflect, to educate, and (frequently) to vent. All identifying details have been changed. Nothing I write should be taken as medical advice. Use as directed. In case of fire . . . . Well, you get the idea -- all the usual disclaimers apply!